Motivational Interventions Motivational Interventions for Special Populationsfor Special Populations

Kathleen Carroll, PhD Kathleen Carroll, PhD Jose Szapocznik, PhD Jose Szapocznik, PhD Antoine Douaihy, MDAntoine Douaihy, MD

Motivational Interviewing (MI)Motivational Interviewing (MI) Overview of Theory, Principles, Overview of Theory, Principles,

Training, and TargetingTraining, and Targeting Special PopulationsSpecial Populations

Antoine Douaihy, MDAntoine Douaihy, MDAssociate Professor of PsychiatryAssociate Professor of Psychiatry

Medical DirectorMedical DirectorAddiction Medicine ServicesAddiction Medicine Services

Western Psychiatric institute and ClinicWestern Psychiatric institute and ClinicAppalachian TriAppalachian Tri--State NODE of CTNState NODE of CTN

MINTMINTdouaihya@upmc.edudouaihya@upmc.edu

DisclosuresDisclosures

AstraZeneca, NIDA, NIAAA: Research AstraZeneca, NIDA, NIAAA: Research SupportSupport

Is this MI?Is this MI?

AcknowledgementsAcknowledgements

Members of the Motivational Interviewing Members of the Motivational Interviewing Network of Trainers (MINT)Network of Trainers (MINT)

Information about recent work and workInformation about recent work and work--inin--progress progress Use and adaptation of slide materialsUse and adaptation of slide materialsInsight into the history and development of MI Insight into the history and development of MI

Dennis C. Daley, PhD; Thomas Kelly, PhD Dennis C. Daley, PhD; Thomas Kelly, PhD IhsanIhsan M. M. SalloumSalloum, MD, MPH: Collaborators , MD, MPH: Collaborators in work on MI in work on MI

BACKGROUNDBACKGROUND Theory and ResearchTheory and Research

Experimental Social Experimental Social PsychologyPsychology

Motivational Stages of Motivational Stages of ChangeChange

Humanistic PsychologyHumanistic Psychology

BACKGROUNDBACKGROUND Experimental Social PsychologyExperimental Social Psychology

Causal AttributionsCausal Attributions

Cognitive Cognitive DissonanceDissonance

Psychological Psychological ReactanceReactance

SelfSelf--EfficacyEfficacy

PrecontemplationPrecontemplation

ContemplationContemplation

MaintenanceMaintenance

Preparation/PlanningPreparation/Planning

ActionAction

Transtheoretical Change ProcessHOW PEOPLE CHANGE

BACKGROUNDBACKGROUND Humanistic PsychologyHumanistic Psychology

IndividualIndividual, not Label, not Label

EmpathyEmpathy, not Direction, not Direction

ClientClient--centeredcentered, not Therapist, not Therapist--DrivenDriven

AcceptanceAcceptance, not Confrontation, not Confrontation

MODEL DEVELOPMENT & TESTINGMODEL DEVELOPMENT & TESTING Stages of ResearchStages of Research

Stage I (Development)Stage I (Development)--19601960’’s Supportive referral encouragement s Supportive referral encouragement (Chafetz)(Chafetz)--19701970’’s Simple advice and referral s Simple advice and referral (Edwards)(Edwards)

Stage II (Efficacy)Stage II (Efficacy)--19801980’’s Motivational Interviewing s Motivational Interviewing (Miller & Rollnick)(Miller & Rollnick)

DrinkerDrinker’’s Checks Check--up up (Miller & Sovereign)(Miller & Sovereign)Stage III (Effectiveness/Multisite)Stage III (Effectiveness/Multisite)

--19901990’’s Motivational Enhancement Therapy s Motivational Enhancement Therapy (MATCH; Miller et (MATCH; Miller et al)al)

--20002000’’s WHO, Marijuana Treatment, Clinical Trials Networks WHO, Marijuana Treatment, Clinical Trials Network

Principles of MIPrinciples of MIExpress EmpathyExpress Empathy

Accurate understanding of the personAccurate understanding of the person’’s s experience, communicated without judgmentexperience, communicated without judgment

Develop DiscrepancyDevelop DiscrepancyDistance between current state and goals, and/or Distance between current state and goals, and/or current behavior and valuescurrent behavior and values

Roll with ResistanceRoll with ResistanceDefensiveness is a signal to respond differentlyDefensiveness is a signal to respond differently

Support SelfSupport Self--efficacyefficacyBelief in ability to succeed at tasks undertakenBelief in ability to succeed at tasks undertaken

Spirit of MISpirit of MI

Autonomy Autonomy Personal responsibilityPersonal responsibilityNeither imposition nor coercionNeither imposition nor coercion

Collaboration Collaboration Meeting of aspirationsMeeting of aspirationsNeither exhortation nor persuasionNeither exhortation nor persuasion

Evocation Evocation Drawing outDrawing outNeither instilling nor installingNeither instilling nor installing

Amrhein, Miller, Yahne, Palmer, Amrhein, Miller, Yahne, Palmer, & Fulcher, 2003& Fulcher, 2003

JCCP, 71: 862JCCP, 71: 862--878878

Psycholinguistic analysis of process in MI Psycholinguistic analysis of process in MI sessions for drug abuse treatment (MIDAS)sessions for drug abuse treatment (MIDAS)

Desire: Desire: ““I want to do this.I want to do this.””Ability: Ability: ““I can do this.I can do this.””Reasons: Reasons: ““This will help me feel better.This will help me feel better.””Need: Need: ““I must do this.I must do this.””

DARN does not independently predict DARN does not independently predict behavior changebehavior changeDARN predicts commitment languageDARN predicts commitment language

Amrhein, Miller, Yahne, Palmer, & Amrhein, Miller, Yahne, Palmer, & Fulcher, 2003Fulcher, 2003

Commitment Language Commitment Language ““II’’m not planning to do this.m not planning to do this.””

““I might do this sometime.I might do this sometime.””

““I am going to do this now.I am going to do this now.””

Increasing intensity of commitment Increasing intensity of commitment language over the course of a session language over the course of a session independently predicts behavior changeindependently predicts behavior change

Other Process FindingsOther Process Findings

Moyers, Miller, & Hendrickson, 2005Moyers, Miller, & Hendrickson, 2005——JCCP, 73: JCCP, 73: 590590--598598

MIMI--consistent interpersonal skills facilitate client consistent interpersonal skills facilitate client involvement (affect, cooperation, disclosure)involvement (affect, cooperation, disclosure)

Moyers & Martin, 2006Moyers & Martin, 2006——JSAT, 30: 245JSAT, 30: 245--251251MIMI--consistent behaviors increased probability of client consistent behaviors increased probability of client change talk (strongest predictor)change talk (strongest predictor)MIMI--inconsistent behaviors increased probability of client inconsistent behaviors increased probability of client countercounter--change talk (strongest predictor)change talk (strongest predictor)

Karno & Longabaugh, 2005Karno & Longabaugh, 2005——JCCP, 73: 262JCCP, 73: 262--267267Among patients with medium/high levels of reactance, Among patients with medium/high levels of reactance, directiveness (interpretation, confrontation, introduction directiveness (interpretation, confrontation, introduction of topics) was associated with worse outcomesof topics) was associated with worse outcomes

A Path Model of MIA Path Model of MI

DesireDesireAbilityAbilityReasonsReasonsNeedNeed

CommitmentCommitment

ChangeChange

MIHigh Empathy

High DiscrepancyHigh Self-EfficacyLow Resistance

EFFICACY & EFFECTIVENESS EFFICACY & EFFECTIVENESS SubpopulationsSubpopulations

Heavy or Problem DrinkersHeavy or Problem DrinkersAlcohol Abuse or Dependence Alcohol Abuse or Dependence Heroin, Cocaine, Methamphetamine, Heroin, Cocaine, Methamphetamine, Marijuana, and Polydrug Marijuana, and Polydrug Dually Diagnosed PatientsDually Diagnosed PatientsTreatment adherenceTreatment adherenceAdolescentsAdolescentsOther Health Risk Behavior GroupsOther Health Risk Behavior Groups

MI TRAINING RESEARCHMI TRAINING RESEARCH Current ProjectsCurrent Projects

Motivational Interviewing Network of Motivational Interviewing Network of Trainers Trainers (MINT)(MINT)

University of New Mexico Center on Alcoholism, University of New Mexico Center on Alcoholism, Substance Abuse and Addictions (CASAA)Substance Abuse and Addictions (CASAA)

NIDA Behavioral Therapy Training ProjectsNIDA Behavioral Therapy Training ProjectsNIDA Clinical Trials Network ProtocolsNIDA Clinical Trials Network ProtocolsTherapy Training Integrity ProceduresTherapy Training Integrity Procedures

MI TRAINING RESEARCHMI TRAINING RESEARCH Current State of KnowledgeCurrent State of Knowledge

TwoTwo--day training results in increased day training results in increased knowledge of MI and satisfaction with knowledge of MI and satisfaction with training procedurestraining proceduresTraining improves MI skills better than Training improves MI skills better than it suppresses nonit suppresses non--MI skillsMI skillsMI skills learned are lost over time MI skills learned are lost over time unless intensive and/or ongoing unless intensive and/or ongoing supervision providedsupervision provided

((Baer et al, 2003; Miller & Mount, 2001; Rubel et al, 2000)Baer et al, 2003; Miller & Mount, 2001; Rubel et al, 2000)

Motivation Interviewing (MI) and Motivation Interviewing (MI) and Enhancement Therapy (MET)Enhancement Therapy (MET)

Clinical Trials NetworkClinical Trials Network

MET for pregnant womenMET for pregnant womenMET for Spanish Speaking Clients MET for Spanish Speaking Clients MET for African American Clients (? MET for African American Clients (? Proposed)Proposed)

Case of AdolescentsCase of Adolescents Help Me, But Don’t Tell Me

What to Do!

Normal Adolescent (12-17) and Young Adult (18-25) Development

• Biological changes in the body, brain, and hormonal systems thatcontinue into mid-to-late 20s

• Shift from concrete to abstract thinking• Improvements in the ability to link causes and consequences

(particularly strings of events over time)• Separation from a family-based identity and the development of peer

and individual-based identities• Increased focus on how one is perceived by peers• Increasing rates of sensation seeking/experimenting• Development of impulse control and coping skills• Concerns about avoiding interpersonal emotional or physical violence• Realizing that they are not invincible to environmental risks (which are

often less proximate or likely)

Conceptual Challenges to Address

• Most adolescents do not recognize their substance use as a problem and are being mandated to treatment (and are angry about it)

• Co-occurring problems (mental, trauma, legal) are the norm and often predate substance use

• Treatment has to take into account the multiple systems (peers, family, school, welfare, criminal justice) involved in their lives

• Adolescents have less control of their lives and recovery environment than adults

• Need to be creative in dealing with family and peer relationships because they are still central to the adolescent’s self-identity and are not easily changed

Family, Peer Groups, and Community

• Families often play a pivotal role, but vary in their ability and willingness to help

• Peer groups are very powerful – but can have both negative and positive effects

• One or two very disruptive people can destroy a group and actually lead to worse outcomes

• Need to minimize confrontational approaches unless you have the time and control necessary to do them well and safely

• Less availability of aftercare, 12-step groups and peer based recovery support

Adapting Interventions• Examples need to be reflect the substances, situations,

and triggers relevant to adolescents• Motivational strategies and consequences have to reflect

things of concern to adolescents• Concepts need to be expressed in “concrete” (vs.abstract)

terms to match developmental stage• Curricula need to take into account individual differences

in severity, co-occurring problems, and development – which often change during the course of treatment

• Need for treatment facilities that are physically durable and to have access to recreational facilities

MIMIMarlatt et al randomly assigned high school seniors (female: 188subjects; male: 160 subjects) to an individualized, brief, MI intervention during their freshman year in college or to a no-treatment condition. Subjects were screened during high school, and no subjects 19 years of age were included. Subjects received 1 MI session during the winter term of their

freshman year in college.Outcome measures included drinking rates, alcohol-related problems, and alcohol dependence. Self-reports of quantity, frequency, and peak alcohol consumption were collected and collateral reports were used to corroborate reports

Marlatt et al, 1998 Deas D, 2008: Evidence-based treatment for alcohol use disorders in

adolescents

Marlatt et al, 1998Marlatt et al, 1998

The MI group demonstrated significant decreases in drinking and reductions in alcohol-related consequences. The significant reductions in drinking were demonstrated in both short-term and long-term drinking outcomes. At the 6-month follow-up assessment, subjects in the MI group drank significantly less frequently and drank smaller quantities over time, and their peak quantity was smaller. These positive outcomes persisted at the 2-year follow-up assessment, again with significantly lower frequency, quantity, and peak alcohol consumption for the MI group, compared with the control group.

McCambridge & Strang 2004Randomly assigned 200 adolescents (age range: 16–20 years; mean age not indicated) to 1 session of MI versus a non intervention,education-as-usual, control condition. Baseline assessments included peer interviews, self-reports of drug use, and testing of hair samples for biochemical validation of drug use. The outcome variables were changes in drug use (nicotine, alcohol, cannabis, and other drug use), changes in drug-specific perceptions, and changes in behavioral outcomes. At baseline, 11 subjects in the intervention group and 17 subjects in the control group were identified as nondrinkers. The 3-month follow-up evaluation revealed that 13 nondrinkers (1 from the MI group and 12 from the control group) had initiated drinking. Overall, the MI group showed significant reductions in nicotine,alcohol, and marijuana use.

Tevyaw & Monti, 2004Tevyaw & Monti, 2004

Review paper Review paper FINDINGS: Results from recent clinical trials FINDINGS: Results from recent clinical trials using motivational interventions indicate that using motivational interventions indicate that these approaches result in decreases in these approaches result in decreases in substancesubstance--related negative consequences and related negative consequences and problems, decrements in substance use and problems, decrements in substance use and increased treatment engagement, with results increased treatment engagement, with results particularly strong for those with heavier particularly strong for those with heavier substance use patterns and/or less motivation to substance use patterns and/or less motivation to change. change.

Peterson et al, 2006Peterson et al, 2006The short-term results of a randomized trial testing a brief feedback and motivational intervention for substance use among homeless adolescents are presented. Homeless adolescents ages 14–19 (N 285)Recruited from drop-in centers at agencies and from street intercept Randomly assigned to either a brief motivational enhancement (ME) group or 1 of 2 control groups. The 1-session motivational intervention presented personal feedback about patterns of risks related to alcohol or substance use in a style consistent with motivational interviewing.Follow-up interviews were conducted at 1 and 3 months postintervention.Youths who received the motivational intervention reported reduced illicit drug use other than marijuana at 1-month follow-up compared with youths in the control groups. Treatment effects were not found with respect to alcohol or marijuana. Post hoc analyses within the ME group suggested that those who were rated as more engaged and more likely to benefit showed greater drug use reduction than did those rated as less engaged.

Grenard et al, 2006Grenard et al, 2006Studies of brief motivational interviewing (MI) interventions aStudies of brief motivational interviewing (MI) interventions applied to pplied to adolescents (ages 13 to 18 years) and young adults (ages 19 to 2adolescents (ages 13 to 18 years) and young adults (ages 19 to 25 years) 5 years) using alcohol or other psychoactive substances. using alcohol or other psychoactive substances. 17 clinical studies reported in the literature. 17 clinical studies reported in the literature. This review revealed mixed findings for the efficacy of brief MIThis review revealed mixed findings for the efficacy of brief MI among these among these populations. populations. However, in 29% of the studies (5 of 17), there was a clear advaHowever, in 29% of the studies (5 of 17), there was a clear advantage of the ntage of the brief MI demonstrated compared to standard care brief MI demonstrated compared to standard care Components common to successful brief MI interventions included Components common to successful brief MI interventions included oneone--onon--one sessions and feedback on substance use compared to norms. one sessions and feedback on substance use compared to norms. Interviewer empathy has been shown to be a key component in studInterviewer empathy has been shown to be a key component in studies with ies with adults, but this was not measured in a standardized manner acrosadults, but this was not measured in a standardized manner across the s the current studies. current studies. The studies reviewed here indicate that brief MI might be effectThe studies reviewed here indicate that brief MI might be effective among ive among these populations, but the key components necessary for successfthese populations, but the key components necessary for successful MI ul MI interventions have not been fully identified. interventions have not been fully identified.

Stein et al, 2006Stein et al, 2006

Motivational Interviewing (MI) to reduce alcohol and marijuana-related driving events among incarcerated adolescentsAdolescents were randomly assigned to receive MI or Relaxation Training. As compared to RT, adolescents who received MI had lower rates of drinking and driving, and being a passenger in a car with someone who had been drinking. Effects were moderated by levels of depression.At low levels of depression, MI evidenced lower rates of these behaviors; at high levels of depression, effects for MI and RT were equivalent. Similar patterns were found for marijuana-related risky driving, but effects were nonsignificant.

Bill MillerBill Miller

After 30 years of research, we have a treatment After 30 years of research, we have a treatment method that is method that is evidenceevidence--based based (over 180 (over 180 randomized clinical trials published), randomized clinical trials published), relatively relatively briefbrief (typically 1(typically 1--3 sessions), 3 sessions), specifiablespecifiable, , grounded in testable theorygrounded in testable theory with identifiable with identifiable mechanism of action, mechanism of action, verifiableverifiable (as to whether it (as to whether it is being delivered competently), is being delivered competently), generalizablegeneralizableacross a wide range of problem areas, and across a wide range of problem areas, and learnablelearnable by a broad range of providers. And we by a broad range of providers. And we are just getting started!!!!!are just getting started!!!!!